Columbia Shuttle

Shuttle Disintegrates Upon Reentry
On February 1, 2003 seven astronauts perished when their Columbia Shuttle disintegrated as it reentered the earth’s atmosphere. During launch a piece of foam insulation, similar in composition to a Styrofoam cup and about the size of a briefcase, broke away from the main propellant tank. The foam struck the left wing seriously breaching the protective panels on its leading edge (Gehman, 2003).

Familiar Problem
It was not the first time that a section of foam had broken away during launch. In fact, it had happened on every previous flight. But on each of these flights the spacecraft reentered the earth’s atmosphere without incident and safely returned home.  With no evidence that harm was done to the spacecraft, management assumed that it was a problem of minor significance and that it did not increase the risk level of the flight (Starbuck and Farjoun, 2005).

Technical or Management Problem?
Just after the 2003 tragedy occurred many experts concluded that technology was to blame. But a more thorough and comprehensive investigation, undertaken by the Columbia Accident Investigation Board, CAIB, concluded differently. It maintained that management was as much to blame for the failure as was the foam strike. The Board described an organizational culture in which, at every juncture, program managers were resistant to new information. It was a culture in which people were unwilling to speak up or if they did speak up were never heard. In their report they wrote that the organizational failure was a product of NASA’s history, its culture, and its politics. (Columbia Accident Investigation Board, 2003).

Lessons Learned
While there are many lessons that can be learned from this disaster, the one that stands out is what organizational psychologists refer to as the “recency effect.” It occurs when decision makers rely on only the most recent information. In this situation foam insulation had broken away on previous flights and caused no harm. To those responsible for the mission, these recent events distorted the real danger presented by this problem.

In addition to the recency effect, a second factor was conservatism, a situation in which new information is ignored or given too little weight. Senior management largely ignored the data from previous flights where foam had broken away on every launch; they failed to revise their prior belief that the system was operating properly.

A third factor was overconfidence. During the flight, engineers, concerned that the foam strike may have caused a problem, asked the Mission Management Team (MMT) to request satellite imagery of the spacecraft. Management, however, was apparently confident that there was no safety issue and a decision was made against imagery. Had the imagery been authorized, and the damage discovered, the conjecture is that a rescue attempt would have had a reasonable chance of success.

A fourth factor may have been selective perception in which management of the shuttle program had shifted from an engineering focus to a managerial focus. This shift was captured by an organizational culture whose motto was “Better, Faster and Cheaper.” It created a culture in which engineering problems were less likely to be recognized and more likely to be dominated by schedules and budgets (Gehman, 2003).

 

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